Increasingly, patients wish to have some choice in their treatment, and to be informed about their options. Conversely, long-term psychiatric in-patients may receive potentially harmful medication for decades, sometimes compulsorily, because of chronic illness. Their wishes may be overridden under the Mental Health (Scotland) Act 1984, which offers the right of appeal and review of treatment. Psychiatrists have, therefore, a particular responsibility to consider the ability of patients to give informed consent and, if they are unable to do so, to ensure that they are given the protection available under the Mental Health Act.
The Department of Health and the Welsh Office (1993) defines consent to treatment as “the voluntary and continued permission of the patient to receive a particular treatment based on an adequate knowledge of the purpose, nature, likely effects and risks of that treatment including the likelihood of its success and any alternatives to it. Permission given under any unfair undue pressure is not ‘consent’.” (our emphasis.) ‘Voluntary permission’ assumes that patients realise that they have a choice and agree to treatment in the absence of duress. There is little published research on the knowledge patients have of their medications, or of their rights to refuse treatment. In one depot clinic, 48% of patients did not realise they had a choice about receiving treatment (Reference Eastwood and PughEastwood & Pugh, 1997). Long-term in-patients may be even less aware of their rights.
‘Adequate knowledge’ of the purpose of medication depends on the clinician explaining treatment and the patient's capacity to understand. Roth et al (Reference Roth, Meisel and Lidz1977) proposes five tests of capacity to consent, increasing in stringency from absence of refusal to full understanding of the information. Patients should be informed of any risks of treatment that a prudent person would regard as significant, as well as the risks of having no treatment.
In this study we assessed the nature and degree of informed consent in long-term psychiatric in-patients, with particular reference to these three criteria:
(a) voluntary and continued permission
(b) knowledge of purpose of treatment
(c) knowledge of risks of treatment.
Material and methods
Our sample comprised all 70 in-patients on three wards at Bellsdyke Hospital, Larbert, Scotland. The Forth Valley Ethics Committee approved the study.
A semi-structured interview was undertaken in March 1998 by one interviewer (N.B.). Subjects were asked about the purpose and side-effects (as defined by the British National Formulary; British Medical Association & Royal Pharmaceutical Society of Great Britain, 1998) of their medication, whether staff had explained their drug treatment, their willingness to take their medications and their belief about their right to refuse it. Comparisons between groups were made using two-tailed χ2 or Fisher's exact tests. Data were analysed using SPSS (Version 9 for PCs).
The characteristics of the 68 patients who agreed to be interviewed are summarised in Table 1. Forty patients (59%) were male and 44 (65%) were over 50; 35 (52%) were detained. There were no informal patients under the age of 50. Fifty-five (81%) patients had schizophrenia, 9 (13%) affective disorders and 4 (6%) other diagnoses on case note review. Twenty-eight (41%) had been in hospital less than 5 years and 30 (44%) had been in for 10 years or more. The results found in voluntary patients are contrasted with detained patients in Table 2.
|Characteristic||Number of patients|
|> 50||44 (65)|
|Bipolar affective disorder||5 (7)|
|Length of stay (years)|
|< 5||28 (41)|
|> 10||30 (44)|
|Knowledge/attitude||Detained (n=35)||Voluntary (n=33)||P|
|n (%)||n (%)|
|Knowledge of the purpose of all medications||12 (34.3)||1 (3)||0.001|
|Knowledge of side-effects||5 (14.3)||2 (6.1)||0.429|
|Remembered receiving explanation from staff||5 (14.3)||4 (12.1)||1.0|
|Happy to take all medications||19 (54.3)||26 (78.8)||0.042|
|Felt they had a choice||4 (11.4)||5 (15.2)||0.73|
Patients were on a median of two preparations (range: 1-5); 55 (81%) were on oral antipsychotics, 24 (35%) on antidepressants, 22 (32%) on depot antipsychotics and 13 (19%) on lithium. Knowledge and attitudes were not associated with preparation (Table 3).
|Oral antipsychotic (n=55)||Intramuscular depot antipsychotic (n=22)||Antidepressant (n=24)||Lithium (n=13)|
|Knowledge/attitude||n (%)||n (%)||n (%)||n (%)|
|Knowledge of the purpose of medications||12 (24)||6 (30)||10 (40)||6 (48)|
|Knowledge of side-effects||6 (12)||5 (25)||2 (8)||3 (24)|
|Remembered receiving explanation from staff||8 (16)||3 (15)||6 (24)||1 (8)|
|Happy to take medication||41 (82)||16 (80)||17 (68)||9 (72)|
|Believe they can refuse medication||7 (14)||2 (9)||3 (12)||2 (16)|
Of the detained patients, 26 (74%) were on Form 9 (i.e. they were considered to have given informed consent to their medication) and nine (26%) were on Form 10 (i.e. unable or unwilling to consent).
Of the patients, 44 (65%) did not know the purpose of any of their medications. Only 13 patients (19%) knew the purpose of all their medications. Knowledge was greater in detained patients (Fisher's exact test, P=0.001) and those who had been in-patients for less than 10 years (χ2=9.6, d.f.=1, P<0.002).
Fifty-five patients (81%) did not know of any side-effects of their medications and only seven patients (10%) knew some side-effects of all their medications. Knowledge was greater in those who had been inpatients for less than 10 years (χ2=4.0, d.f.=1, P<0.04).
Forty-five patients (66%) were willing to take all their medications; 12 patients (18%) were unwilling to take any of them. Willingness was greater in females (χ2=4.3, d.f.=1, P<0.04), those who had been inpatients for more than 5 years (χ2=6.9, d.f.=1, P<0.0009) and voluntary patients (Fisher's exact test, P=0.04).
Four (11%) of the detained patients wrongly thought they had the right to refuse medication and 27 (82%) of the informal patients thought they had no right to refuse medication.
Nine patients (13%) recalled staff explaining medication. This was not associated with age, gender, length of stay or legal status.
We have found that long-term in-patients had little knowledge of medication, or their right to refuse it, but despite this most were happy to take it. Those deemed most able to give informed consent, that is, voluntary patients, knew least about their medication. Few patients met all three criteria for informed consent.
Lack of knowledge about the right to refuse medication was the most striking result, with 82% of informal patients wrongly thinking they had no choice. This was independent of age, length of stay, legal status or gender. Informal patients in our study may be eluding the safeguards of regular drug review afforded by the Mental Health (Scotland) Act 1984 because their passive acceptance of medication is accepted as informed consent to treatment.
This study has some limitations: the sample is relatively small and from one institution; there may be confounding variables, such as IQ, which we did not study; many of the variables may interrelate, for example, age and length of stay; and we did not investigate compliance with treatment. These issues were not our main focus of interest. Is the sample representative of other long-term patients? Findings elsewhere suggest that it may be. In an American state hospital population, only 8.4% could correctly name at least one of their medications, its dose and intended effect (Reference GellerGeller, 1982). Olin and Olin (Reference Olin and Olin1975) found that only 8% of a state hospital population were fully informed concerning their voluntary admission.
There is evidence that psychiatric patients themselves wish for more information about medications (Macpherson et al, Reference Macpherson, Double and Rowlands1993, Reference Macpherson, Jerrom and Hughes1996), although we did not ask about this. Worries that increasing patients' knowledge would decrease their compliance have not been substantiated (Reference Schnieden, Mealham and GreenbergSchnieden et al, 1991; Reference Rogers, Pilgrim and LaceyRogers et al, 1993).
Our findings raise difficult questions about current psychiatric practice. Are long-term psychiatric inpatients told enough about the risks and benefits of treatment? How, and to what extent, can the prevalence of informed consent be improved in this patient population? Are patients, especially voluntary ones, adequately informed of their rights, and are those rights adequately protected? Are there adverse effects from increasing informed consent? In the absence of conclusive research evidence, the psychiatric professions and all those concerned for patient welfare must debate these questions.